eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Palatal & Maxillofacial Surgery

Snoring and Obstructive Sleep Apnea, Surgery: Workup

Author: Jonathan P Lindman, MD, Consulting Staff, Department of Otolaryngology, ENT Care Associates
Coauthor(s): Charles E Morgan, DMD, MD, Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham
Contributor Information and Disclosures

Updated: Sep 25, 2009

Workup

Laboratory Studies

  • Laboratory studies are generally unnecessary in the workup of a patient with sleep-disordered breathing. A CBC count may be useful if anemia is suspected. Generally, a low-grade polycythemia is present due to chronic or recurrent bouts of hypoxia. A test for growth hormone level or thyroid stimulating hormone level is necessary only if the presence of acromegaly or hypothyroidism is clinically supported.

Imaging Studies

  • Cephalometric radiography (plain radiography of the airways): The value of radiography in routine presurgical workup is highly debated. The study is most useful in assessing craniofacial skeletal abnormalities. Lateral airway images can be helpful in diagnosing adenoid hypertrophy in young pediatric patients.
  • CT scanning or MRI: These procedures are rarely performed in the workup for obstructive sleep apnea (OSA) because they do little to guide therapeutic intervention, they are expensive, and they expose patients to unnecessary radiation.
  • Chest radiography: Radiographs may depict right ventricular hypertrophy due to persistent pulmonary vasoconstriction (cor pulmonale).

Other Tests

  • Electrocardiography may be useful in evaluating for cardiac dysrhythmias.

Diagnostic Procedures

  • Polysomnography is the criterion standard for diagnosing sleep apnea.
    • Diagnostic information gathered in a sleep laboratory includes the stages of sleep and the number and types of apneic events.
    • Continuous oxygen saturation monitoring and continuous ECG tracings are also performed.
    • A complete polysomnographic study includes electroencephalography for sleep staging, bilateral electro-oculography, submental electromyography, nasal and oral air-flow assessments, respiratory muscle movement or effort assessment, oxygen saturation testing, electrocardiography, anterior tibialis electromyography, and sleep-position assessment.
    • The study should be completed during the patient's normal sleep time and include a minimum of 2-4 hours of sleep.
  • Several parameters may be measured.
    • The apnea index is defined as the number of apnea episodes per hour. Apnea is defined as the absence of airflow at the nose and mouth that lasts for at least 10 seconds during sleep.
    • The respiratory disturbance index (RDI), or apnea-hypopnea index (AHI), is defined as the combined number of apneic and hypopneic events per hour of sleep.
    • Hypopnea means underbreathing and is relatively more difficult to define. Most agree that airflow must be decreased by about 50% and associated with about a 4% decrease in blood-oxygen saturation to be considered hypopnea. Some add an arousal from sleep to this definition. The authors define hypopnea as a reduction in airflow of 30% or greater for 10 seconds or longer associated with an oxyhemoglobin desaturation of 4% or more.
    • The association of sleep-disordered breathing with cardiovascular disease has been reported in 5250 patients.9
    • The RDI, lowest oxygen saturation(s) level for the night, length of time with oxygen saturation less than 90%, and ECG findings are the most important factors. Surgeons use these parameters to determine treatment options based on the severity of the apnea.
    • The severity of OSA is arbitrarily defined and differs widely among centers. Recent recommendations for cutoff levels based on RDIs are as follows:
      • Mild OSA is defined as 5-15 episodes per hour.
      • Moderate OSA is defined as 15-30 episodes per hour.
      • Severe OSA is defined as more than 30 episodes per hour.
  • Home polysomnography: This portable form of sleep study has gained limited acceptance because trained or qualified personnel often do not perform the test. A recent study compared a widely available home unit (SNAP) with a 12-lead sleep-laboratory polysomnography. Although not widely accepted, SNAP is considered by the authors to be a suitable alternative to traditional polysomnography.10
  • Nocturnal oximetry: If the patient's oxygen saturation is below 90% during less than 1% of his or her sleep time, apnea is not clinically significant.
  • Acoustic recording: An audio recording is analyzed for apneic episodes, primarily to help confirm the diagnosis in children. However, this test has a poor predictive value if the results are negative. Nocturnal polysomnography remains the diagnostic criterion standard in children and adults.

More on Snoring and Obstructive Sleep Apnea, Surgery

Overview: Snoring and Obstructive Sleep Apnea, Surgery
Workup: Snoring and Obstructive Sleep Apnea, Surgery
Treatment: Snoring and Obstructive Sleep Apnea, Surgery
Follow-up: Snoring and Obstructive Sleep Apnea, Surgery
Multimedia: Snoring and Obstructive Sleep Apnea, Surgery
References
Further Reading
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References

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Further Reading

Clinical guidelines

University of Texas, School of Nursing, Family Nurse Practitioner Program. Screening for obstructive sleep apnea in the primary care setting. Austin (TX): University of Texas, School of Nursing; 2006 May. 13 p.

Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea in adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Jun. 55 p.

Scottish Intercollegiate Guidelines Network (SIGN). Management of obstructive sleep apnoea/hypopnoea syndrome in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2003 Jun. 35 p.

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Keywords

snoring and obstructive sleep apnea, obstructive sleep apnea, snoring, surgery for obstructive sleep apnea, OSA, surgery for sleep-disordered breathing, obstructive apnea, peripheral apnea, sleep apnea, sleep-induced apnea, Ondine curse, Ondine's curse, frequent awakening, daytime sleepiness, sleep disorder, apnea index, respiratory disturbance index, RDI, uvulectomy, nasal reconstruction, adenotonsillectomy, palatal implants, uvulopalatopharyngoplasty, UPPP, UP3, genioglossal advancement with hyoid myotomy, maxillary-mandibular advancement, bimaxillary advancement, palatal advancement, tongue-base surgery, midline glossectomy, tracheostomy, continuous positive airway pressure, CPAP, bilevel positive airway pressure, Bi-PAP, Pillar system, Pillar procedure, transpalatal advancement pharyngoplasty, thyrohyoid suspension, radiofrequency ablation, tracheotomy

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Contributor Information and Disclosures

Author

Jonathan P Lindman, MD, Consulting Staff, Department of Otolaryngology, ENT Care Associates
Jonathan P Lindman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Phi Beta Kappa, and Triological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Charles E Morgan, DMD, MD, Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham
Charles E Morgan, DMD, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society
Disclosure: GE Healthcare Honoraria Review panel membership

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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